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An Integrative Approach to Caring as Nursing Science Using Narrative, Reflective Practice, and Standardized
Nursing Languages in the Electronic Age
DOKUMENTATIONSKONFERENCE 2020
Dansk Sygepleje Selskabs Dokumentationsråd
Tirsdag den 3. og onsdag den 4. november 2020
Scandic Sluseholmen
Molestien 11 • 2450 København SV
Howard K. Butcher, PhD; RN
Professor
Director of the PhD in Nursing Program
Christine E. Lynn College of Nursing
Florida Atlantic University
Boca Raton, Florida
Editor, Nursing Intervention Classification (NIC)
Christine E. Lynn College of Nursing
Everglades
Christine E. Lynn College of Nursing
Vision Quest
The advancement of nursing science and art through the unification of caring science, story theory, reflective practice, and standardized nursing languages (NNN) as a guide for nursing education, practice and research.
The Focus of Nursing
The focus of nursing is on facilitating healing, prevention of illness and injury, optimization of health, protection, health promotion, alleviation of suffering, enhancing quality of life, finding meaning, wellbecoming, humanbecoming, nurturing the person in living and growing in caring, and advocacy for environmental and social justice.
Shallow Nursing
EHRs creates a “poverty of attention” because of the mass of disconnected data
EHR limit the space for narrative notes and restrict the inclusion of subjective/nuanced interpretations which are either not documented, hidden, or fragmented.
Shallow Nursing and the Mechanisms of Dehumanization
Automation of Care- AI, Algorithms, Machine learning
SNL “ignores nursing theory,” and can’t classify the focus of nursing such as the social lifeworld, suffering, coping, spirituality, and vulnerability (Benner, 2004).
Formalization of nursing care can not capture invisible practices like: meaning and intentionality; context; multiplicity of intents; relational, emotional, interpersonal work; understanding of the situation; moods, climates, and cultural sets (Benner, 2004)
Deep Nursing
Embraces nursing as a humanistic science
Nursing Theory Guided
Person-Centered
Grounded in caring nursing theories (Watson, Roach, Boykin & Schoenhofer)
Places emphasis on story and narrative (narrative pedagogy and narrative practice)- Benner, Diekelmann
Reflective nursing practice (Freshwater & Johns)
Empirical, personal, ethical, aesthetic, emancipatory, and unknowing
Nursing Standardized Languages- AI, Big Data, Meaning-Making
Evidenced-Based Praxis
Deep Nursing is Accomplished by Practicing Nursing as Caring
Grounding Nursing in Caring as Nursing Theory (Waston, Roach, Boykin & Schoenhofer
Embracing Narrative (Capturing the Person’s Story)
Integrating Reflective Practice: Revolution in Clinical Decision-Making Models (OPT)
EHR use of Natural language processing capturing(NLP)
Nursing as CaringCare is the essence of nursing (Leininger)
Caring is a human mode of being (Roach)
All persons are caring (Boykin & Schoenhofer)
Caring is Nursing’s moral imperative (Watson)
The focus of nursing is nurturing of persons living caring and growing in caring
Caring is an intentional process in response to a call for care
Caring occurs with presence in a nursing situation
In the Nursing Situation, the nurse draws on personal, empirical, and ethical knowing to bring to life the artistry of nursing.
Relationships are transformed through caring
Each person grows in caring through interconnectedness with other
Personhood is a process of living grounded in caring
Nursing as Caring
Health is a subjective experience - a unity, person environment harmony
Nursing’s Goal is help persons gain a higher degree of harmony that fosters self-knowledge, self-reverence, self-caring, self-control, finding meaning, informed self determination, and self-healing
The Goal of Nursing is achieved through transpersonal caring processes which are scientific, professional, ethical, aesthetic, creative, and personalized
Transpersonal caring refers to values of deep connectedness, of relationship, subjective meaning, and shared humanity . . . Transpersonal conveys a connection beyond the ego, capturing spiritual dimensions all humans share with a deeper self, others, nature, and the universe.
Transpersonal caring helps restore inner harmony while contributing to the both the nurse and patient in finding meaning and harmonizing of the experience
Deep Nursing: Narrative Roots
Nightingale used Narrative to “tell the story” of her successes in the Crimean War. First she wrote over 100 letters during the war In all, she wrote some 19,000 letters. Her report on the Crimean War was a 853 page treatise “Notes on the Health of the British Army” which she followed up with “Answers to Written Questions.” In reflective remarks she mused on stories of Iphigenia of Tauris; Euripides’ tragedy; Dante’s Inferno, and saw herself in a Greek tragedy like Prometheus bound to a rock. She marketed the report by sending to key people.
Narrative Turn
Spoken or written presentation-Organizational Scheme expressed in a Story form
Evolution of Narrative in the Sciences: “The Narrative Turn” is an epistemological shift from a scientific perspective which values abstract experimentation and generality toward a narrative paradigm which gives primacy to human experience and subjectivity. [Dilhey; Bruner; Polkinghorne, Ricoeur]
Applications of Narrative
Existential Phenomenology
Narrative Research
Narrative Therapy
Narrative Pedagogy
Narrative Medicine
Calls for Narrative in Nursing
Boykin & Schoenhofer; Newman, Parse, Peplau, and Watson all call attention to the importance of story
The Carnegie Foundation for the Advancement of Teaching “Educating Nurses: A Call for Radical Transformation.” Twenty-six recommendations:
17) Foster opportunities for educators to learn how to teach students to reflect on their practice.
19) Support educators in learning how to use narrative pedagogies.
Deep Nursing: Narrative in Teaching-Learning
Narrative Pedagogy - Narrative Pedagogy, developed by Diekelmann in 1995, is an interpretive pedagogy that highlights the lived and shared experiences of students and teachers by using feminist, critical, and phenomenological, as well as, conventional approaches, to teaching and learning. Through the use of narratives, students are given opportunities to think, reflect, and analyze problems, solutions, and other issues related to the narratives.
Narrative Medicine (Health Care)
A rigorous intellectual and clinical discipline to fortify healthcare with the capacity to skillfully receive the accounts persons give themselves---to recognize, absorb, interpret, and be moved into action by the stories of others as a means to improve healthcare.
• Challenge fragmented, reductionistic practices that have little regard for singular aspects of a patient’s life; a protest against discriminatory practices and policies
• Deepen therapeutic partnerships
• Improve accuracy of clinical knowledge
• Rita Charon-Columbia University
Classification/Standardization of Nursing Knowledge (NANDA-NIC-NOC)
Driven by demands for: making nursing care visible; electronic planning, documenting, retrievable patient information for analytics; organizing curricula and staff education; facilitating clinical decision making; communication of care, determining appropriate allocation of resources and costing of nursing services; foundation for intervention testing and effectiveness research to establish the scientific evidence for guiding practice.
Enhancing the quality, effectiveness, and safety of care
EHR: Discrete Information vs Natural Language
Clinicians find value in both forms of information. The efficient administration of healthcare demands discrete, encoded data. Discrete data is ideal for quickly noting trends, graphing, encoding and machine processing for myriad uses.
Narrative text tells the patient's unique health story, including the more nuanced details of their symptoms and disorders. The narrative describes the patient's preferences and care priorities, and provides an expanded picture of the patient's social history. These details are vital to good patient care and are required for effective communication between healthcare providers and between providers and patients.
Reflective Practice
Reflection is a process of transforming self as necessary to realize desirable practice
Christopher Johns
Reflection-in-ActionCore Question: What information do a need to nurse (or use this skill/ procedure)?
Cue Questions:
• Who is this person?
• What health event brings the person to the hospital?
• How is this person feeling?
• How is this event affected their usual life pattern and roles?
• How does this person make me feel?
• How can I help this person?
• What is important for this person to make their experience of this procedure comfortable?
• What support does this person have in life?
• How does this person view the future for themselves and others?
REFLECTION: AESTHETIC KNOWING
What was I trying to achieve?
• Why did I respond as I did?
• How did I try to make the experience more comfortable for the patient?
• How was this person feeling and how could I know this?
• What factors helped me act in congruent or incongruent ways?
REFLECTION: ETHICAL KNOWING
How did my actions match with my beliefs?
What ethical principles may be involved in this situation?
REFLECTION: EMPIRICAL KNOWING
What theoretical knowledge did or should have informed me as I learned and performed this procedure?
REFLECTION: PERSONAL KNOWING
How did I feel in this situation?
What past experiences and knowledge influenced me as I was doing this procedure?
NURSING STANDARDIZED LANGUAGES NANDA-NIC-NOC
NURSING INTERVENTIONS
The Nursing Interventions Classification (NIC)
“is a comprehensive, research-based, standardized classification of interventions that nurses perform. It is useful for clinical documentation, communication of care across settings, integration of data across systems and settings, effectiveness research, productivity measurement, competency evaluation, reimbursement, and curricular design” (p. 2).
An intervention is defined as:
“any treatment, based upon clinical judgment and knowledge that a nurse performs to enhance patient/client outcomes”(p. 2).
Butcher. H.K. Bulechek, G. M., Dochterman, J. M. & Wagner, C. M. (2018). Nursing Interventions Classification (NIC). (7e). St. Louis: Elsevier.
Classification-systematic arrangement in groups or categories according to established criteria
Taxonomy- (arrangement) the rules or conventions of an order or arrangement (structure) of concepts of knowledge; a systematic structure or knowledge map that exist in all domains of human activity as a means to manage knowledge (things, ideas, times, places) that give a sense of the whole. Must have a controlled or standardized vocabulary to create clarity and meaning.
Classifications organize knowledge
We organize so we can manage
Classifications allow us to:•Retrieve information•Build knowledge•Identify novel relationships•Make sense•Manage complexity•Facilitate decision making•Control the flow of information
Nursing Standardized Languages
Helps demonstrate the impact nursing have on the system of healthcare delivery
Standardizes and defines the knowledge base for nursing curricula and practice
Facilitates communication of nursing treatments to nurses and other health care providers
Enables researchers to examine the effectiveness and cost of treatments
Assists educators to develop curricula that better articulate with clinical practice
Nursing Standardized Languages
Facilitates the teaching of clinical decision making
Assists administrators in planning more effectively for staff and equipment services
Promotes the development of a reimbursement system for nursing services
Facilitates the development and use of nursing information systems
Communicates the nature of nursing to the public
Nursing Interventions: The HOW of Caring
• Interventions are the means of change
• Interventions are the actions taken to improve or help a situation
• Nursing interventions are the essential components that characterizenursing care
• Nursing interventions are the substance in the art of nursing
• Nursing interventions are nursing’s answer to calls for nursing
• Nursing interventions are expressions of caring
• Nursing artistry is reflected in the implementation of nursing interventions
The Classification
NIC 7e comprises of 565 nursing interventions organized into 7 domains and 30 classes representing all nursing practice specialties and setting
NIC Taxonomy of Nursing Interventions: Domains & Classes
Physiological:
Complex
Physiological:
Basic
Behavioral Safety Family Health System Community
Activity & Exercise
Management
Elimination
Management
Immobility
Management
Nutrition
Support
Behavior
Therapy
Cognitive
Therapy
Communication
Enhancement
Coping
Assistance
Electrolyte & Acid-
Base Management
Neurologic
Management
Perioperative
Care
Drug
Management
Respiratory
ManagementPhysical Comfort
Promotion
Self-Care
Facilitation
Skin/Wound
ManagementPsychological
Comfort Promotion
Patient
Education
Crisis
Management
Risk
Management
Childbearing
Care
Childrearing
Care
Health System
Mediation
Health System
Management
Information
Management
Community
Health Promotion
Community Risk
Management
Lifespan Care
Thermoregulation
Tissue Perfusion
Management
A Unified Model for
Nurse-Patient Decision Making
Outcome-Present State-Test Model for Reflective Practice
Revolution in Clinical Decision-Making Models (OPT)
Non-linear
Emphasis is on outcomes
Incorporates “story”
Includes ”reflective practice”
Includes framing within a disciplinary lens (Nursing Theory)
Incorporates NANDA-NIC-NOC
Outcome-Present State-Test Model for Reflective
Practice
Cue
Logic
Reflection
Outcome
State
Present
State
Decision Making
Judgment
Client
-in-
Context
Story
Exit
Framing
Testing
Outcome-Present State-Test Model for Reflective
Practice
Cue
Logic
Reflection
NOC NANDA-I
NIC Interventions & Activities
NOC
Indicators
Client
-in-
Context
Story
Exit
Caring as Nursing
Testing
Smith and Liehr’s Story Theory
What is in the Patient’s Story
• Created to understand and interpret that patient’s trajectory
• It is the “Big Picture”
• Cognitive awareness and understanding
• Relevant history
• Data patterns that emerged during care activities
• Problems identified
• Holistic Care plan
• Synthesis of patient information
Patient’s Story in Context
• Who is the patient
• What is the patient’s story
• How do you describe the patient and his or her story
• How do I think about the patient’s situation
• What contextual factors need to be considered
• What institutional policies and assessment forms are you using that influence your thinking and reasoning about the patient’s story
Source of Story Information
• All inclusive Information (Everything Counts)
• Objective-Subjective
• Conversations
• Patient’s History/Futurey
• Interview
• Health Appraisal
• Family Members
• Lab results/Diagnostic Tests
• Progress Reports
• Rounding
HIMSS HEALTH STORY PROJECT VALUE STATEMENT:Ease of Use:
A health story is the natural by-product of as well as supportive of an efficient clinical workflow, integrating structured and unstructured information.
• Unstructured or semi-structured information must retain a place in the record. It improves the quality of documentation and supports clinical workflow.
• Documentation requirements should not sacrifice the quality of patient-provider interactions.
HIMSS HEALTH STORY PROJECT VALUE STATEMENT:Objectives
• Electronic records must produce a longitudinal record of lasting value. That record must express the thought processes behind the delivery of care, preserving this for future readers.
• The electronic record and new technologies support shared decision-making, document use of practice guidelines, and support evidence-based practice.
HIMSS HEALTH STORY PROJECT VALUE STATEMENT:Quality of Documentation
• A short narrative that pinpoints the key aspects of a patient’s care is more functional than auto-generated, multi-page “summaries.”
• A record chopped into unconnected pieces, without context and lacking pertinent details, is not useful.
“One group that is hard for me to envision ever being replaced in the deep medicine future is
nurses, the real people caring for the sick. That isn’t to say there are not opportunities for AI to
augment nurses’ work” (Topol, 2019, p. 163) Deep Medicine: How Artificial Intelligence Can
Make Healthcare Human Again
Deep Nursing is Meaningful Nursing
•Machine Nursing must not be our future
•Human’s yearn for Presence, Compassion, Trust, Caring, Relationships
•AI and Natural Language Processing Augment Practice
•People need a nurses to alleviating suffering, find meaning, feel listened to, feel understood, experience presence, and experience the laying on hands
Deep Nursing: Using of Natural Language Capturing of the Patient’s Story
• Narrative Mode of Documentation facilitates a caring perspective (von Krogh & Naden, 2011)
• Narrative mode expands understanding through the circular hermeneutic circle and fusion of horizons (Gadamer, 1989)
• False Choice: Deep Nursing is not in Conflict with Nursing Standardized Languages
Natural Language Processing
Natural language processing (NLP) technology enables computers to derive computable and actionable data from text, especially when text is recorded in the form of natural human language (i.e., phrases, sentences, paragraphs).
Allows humans to record information in the most natural method of human communication (narrative text), and then enables computers to extract actionable information from that text.
NLP is also capable of analyzing the often non-standard grammatical constructions common in medical lingo. Natural language understanding (NLU) is a subset of NLP that uses reasoning, inference and semantic searching to help clinicians make decisions and take action.
Natural Language Processing
The global healthcare Natural Language Processing (NLP) market is expected to grow from $1.10 billion in 2015 to $2.67 billion by 2020, according to a new report.
That forecast translates to a compound annual growth rate of 19.2 percent
HealthcareITNews, August 14, 2015
Natural Language Processing is Everywhere
Clara Labs
x.ai
DigitalGenius
Howdy
Jibo
DingDong
Siri
Alexa
Google Home
Apple HomePod
Baidu’s DuerOS
Samsung
Companies Developing Natural Language Processing for Healthcare
CareVoice
Saykara
Augmedix
Sensely
Suki
Notable
Microsoft
Amazon
Nuance
Sopris Health
Orbita
In the age of the EHRs, Standardized Nursing Languages, machine learning, algorithms, and artificial intelligence in healthcare,
the humanness of deep nursing has never been more essential.
Howard Butcher PhD, RNProfessorEditor, Nursing Interventions Classifications (NIC)Christine E. Lynn College of NursingFlorida Atlantic UniversityBoca Raton, Florida, USAEmail: [email protected]
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